Description: A 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain. MI has been ruled out. She has been referred for an exercise echocardiogram.
(Medical Transcription Sample Report)
The patient is a pleasant 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain. MI has been ruled out. She has been referred for an exercise echocardiogram.

Informed written consent has been obtained from the patient. I explained the procedure to her prior to initiation of such. The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position. There were no safety concerns noted by staff nor myself.

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